Citation
A community based needs assessment

Material Information

Title:
A community based needs assessment St. Anthony Hospital Systems, study of Granby, Colorado
Creator:
Stuart, Barbara
Publication Date:
Language:
English
Physical Description:
47, [19] leaves : color charts, maps ; 28 cm

Subjects

Subjects / Keywords:
Health facilities -- Colorado -- Granby ( lcsh )
Health surveys -- Colorado -- Granby ( lcsh )
Public health -- Colorado -- Granby ( lcsh )
Health facilities ( fast )
Health surveys ( fast )
Public health ( fast )
Colorado -- Granby ( fast )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references.
General Note:
Submitted in partial fulfillment of the requirements for a Master's degree in Planning and Community Development, College of Design and Planning.
Statement of Responsibility:
submitted by Barbara Stuart.

Record Information

Source Institution:
University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
09003637 ( OCLC )
ocm09003637
Classification:
LD1190.A78 1981 .S78 ( lcc )

Full Text
5TUA&T
Barbara Stuart Spring, 1981
MPCD THESIS
A Community Based Needs Assessment
St. Anthony Hospital Systems Study of Granby, Colorado
MURP STUDENT PAPER241


A COMMUNITY BASED NEEDS ASSESSMENT
St. Anthony Hospital Systems Study of Cranby, Colorado
A Master's Thesis in partial fulfillment of the requirements for a Masters Degree in Planning and Community Development
Submitted by Barbara Stuart April 30, 1981


I would like to acknowledge the thoughtful and provacative guidance of Miriam Orleans in developing this thesis and the graphic assistance of Carole Steele in preparing the manuscript.


CONTENTS
THESIS STATEMENT......................................... 1
Supporting Discussion ................................. 2-8
THE COMMUNITY
A Description of Granby .............................. 9-19
THE ASSESSMENT
Questionnaire Methodology .............................20-26
The Results ..........................................27-35
The Projections ......................................35-45
CONCLUSION............................................... 4 6
APPENDIX
47


THESIS STATEMENT:
A community based health needs assessment provides vital information to decision makers who shape the health services of a region. Current health planning models based on historical utilization of services ignore the needs of a significant portion of the population.
Health planners are vitally concerned with measuring health
in order to provide information for rational policy making.
The measurement is not always precise because of the broad
range of social determinants for health status. The World
Health organization has defined health as a:
state of complete physical, mental and social well being and not merely the absence of disease or uncertainly.(1)
Another description states that:
...health is not a condition; it is an adjustment. It is not a state but a process.
That process adapts the individual not only to our physical but also to our social environment.(2)
That social environment also shapes health. Because the resources necessary to provide health care are finite and costly, decisions about where to locate the resources and how to pay for them are very political and can sometimes defy quantification. The goal of the planner is to effect the distribution of these resources in an equitable fashion.
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Equitable distribution of health facilities or services is based on accessibility. In order to responsibly plan for the provision of health services, planners must first understand the characteristics of the population which will use the services. Socio-economic factors determine accessibility and health status. There are a number of ways to measure the health status of the population, all yielding a different perspective.
For many years epidemiologists have studied mortality rates to gain a better understanding of the population. As medical technology and pharmaceutical interventions have advanced, mortality trends have been altered dramatically. People are living longer, but chronic illness, (disease of longer duration), is becoming more pronounced. Mortality is being replaced by morbidity as the primary measure of health. (3)
Measurement of morbidity includes a review of death related data as well as disability, signs, symptoms and abnormalities caused by disease. These data are collected through household interviews and questionnaires, physician and hospital reports and public health records. Providers of health care services, as well as some public agencies, have used physician and hospital reports to assess the health of a given population.
It might be more accurate to say the providers assess the morbidity or illness of a population since the product of the provider is usually some sort of medical intervention.
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The problem with using physician and hospital based data to assess health is that it does not represent the total population. Only those who perceive illness and take action to seek care are represented. Users of services are said to make a "demand" for care. The classic graphic description of this problem which follows, was developed by White and others in 1961. As can be seen, only one quarter of the population at risk and one third of the population reporting illness in a month consulted a doctor. Physician and hospital data provide only part of the picture of health in any community.
Factors which influence the decisions of people to seek care are socio-economic as well as dependent upon the supply of and quality of available services. Donabedian, Marcus and others describe the increased utilization of services by low income community numbers.(4,5) This increased utilization may be an indicator of poorer health status. Without the resources to assure proper nutrition or education, low income families are more vulnerable to disease or disability. Less education may mean a more menial occupation and higher risk for disabling injuries.
"Demand" is an economic term; when applied to the users of services it is safe to assume that many of the users can afford to buy health care services. This is particularly true of the clientele who visit physicians offices. Since most insurance benefits do not cover outpatient visits to a doctor's office, an impoverished patient may not seek a doctor's care in the
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MONTHLY PREVALENCE OF ILLNESS & USE OF MEDICAL CARE
Adult population at risk
Adults reporting one or more illnesses or injuries per month Adults consulting a physician one or more times per month Adult patients admitted to a hospital per month Adult patients referred to another physician per month Adult patients referred to a Univ. Med. Ctr. per month
White, K.L., Williams, T.F., and Greenberg, B.G.: The ecology of medical care. N. Engl. J. Med. 265:855-92, 1961.
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early stages of disease. A visit to a physician's office represents out of pocket expense. Instead the client waits until the situation is urgent or critical and then visits a hospital emergency room.
Hospital based demand is especially subject to economic considerations. It can be said that those services which are covered by insurance are used with the greatest frequency.
Wennberg expresses skepticism about the use of these institutional indicators of need (with attendant insurance coverage) using two arguments: 1) prevention and cure for diseases are more often based on changes in life style than in provision of health services and 2) physicians differ in their perceptions of "need" for specific ways of treating illness.(6) An example of this disagreement is the surgeon who believes cancer should be surgically removed, the oncologist, who believes chemotherapy is "the way" and the radiation therapist who treats cancer with radiation. Wennberg further describes the differing need for procedures as an economic variable by showing the dramatic difference in per capita cost for nine common procedures in high and low use areas.
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Procedure High Use Areal Low Use Area1 State Average
Hysterectomy $ 6.78 $ 2.88 $ 4.30
Cholecystectomy2 3 4.98 2.51 3.45
Prostatectomy 3.54 1.47 2.34
Tonsillectomy 4.55 0.85 2.33
Hernia2 2.51 1.64 1.99
Dilation and Curettage 2.68 1.08 1.82
Appendectomy 1.99 0.97 1.47
Hemorrhoidectomy 1.43 0.23 0.54
Varicose Veins 0.93 0.30 0.48
All Nine Procedures 29.39 11.93 18.73
1 Areas ranked independently on procedure
2 For females only
3 For males only
Wennberg, J.E., A. Gittelsohn: Health care delivery in Maine: Patterns of use of common surgical procedures. J. Maine Med Assoc, 66:5, PP. 123-130 and 149.
Wennberg states his concerns as follows:
...Insurance is viewed as a risk-pooling device, as a hedge against the randomness of costly illness. It is assumed that once contact is made with the system, the care provided is generally of value and more or less similar for the same illness.
The distribution of insurance benefits from both public and private markets among Vermont hospital service areas illustrates what is wrong with this assumption. Across neighboring Vermont areas, equal initiating contact for episodes of illness with the system occurs among the elderly, among the poor and among everyone else. Yet contact among these apparently similar cohorts of people results in variable applications of health care technology and is followed by varying per capita expenditures and reimbursements.(7)
Demand driven indicators cannot be used as the sole tool for planning future health services. Insitutional based data of
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demand for services has been commonly used for a number of reasons, 1) the performance of the health sector is politically costly to some professional groups and full blown research into health sector performance which is not professionally controlled is very threatening, 2) the availability of demand based data makes it an attractive tool and 3) many administrators and physicians prefer to use a data base which affords an opportunity for institutional modification.(8)) Community or population based data is perceived to be rife with life style factors which cannot be modified by the construction of a hospital or clinic.
Demand data provide information about the health status of a community from the perspective of the provider of service.
Wide variation in provider practices and age/sex differences among populations make demand driven data studies problematic.(9) It is important to measure the health of the community as perceived by the community as well. One way of doing this is through the community based needs assessment.
The goals of a community based needs assessment are like those of the planner: 1) to define or identify problems, 2) to provide information to formulate priorities and 3) to develop a plan to meet the indicated needs.(10)
This type of study was undertaken by Saint Anthony Hospital in Granby, Colorado. Granby was chosen as the study site for several reasons:
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1. Granby is the location of a SAHS emergency room and clinic. Data from the questionnaire can be used to design programs for the clinic to meet the needs of the community.
2. Members of the community were familiar to me because of many meetings with "key informants" in the area during the development of the clinic proposal. Their responsiveness and encouragement were vital to the success of the questionnaire.
3. Granby appeared to have a fairly stable year round population in an area which experiences a wide variation in seasonal population.
Hospitals can use community based data in conjunction with demand data to plan for future services. Community needs assessment is not costly and need not remain the "mystical experience" available only to public health workers. The private sector is in a unique position of being able to review a more complete picture of a community while being able to modify less relevant or functional features of a health delivery system.


The Community
Saint Anthony Hospital Systems has been working with the local physician and the community to develop a 24 hour emergency room and community clinic in Granby, Colorado. While the very modern building is owned by the physician, Saint Anthony proposed to manage the services provided through the clinic. During the numerous meetings with the citizens of the area to discuss the establishment of the clinic, community residents voiced interest in having specialists available. The type of specialist requested was related to the characteristics of the people in the discussion group. Thus a group of several younger women asked about the potential for having an obstetrician available, while some of the older residents asked about having a "heart" doctor come to the clinic. It became important to the hospital to understand the nature and validity of these articulated needs.
The choice of Granby for the first rural health needs assessment by a private hospital afforded Saint Anthony a unique opportunity. The hospital could learn more about the character of this rural community while being in a position to do something with the findings. Saint Anthony accepted the responsibility for following through with a clinic program based on the report of the survey data. The hospital administration recognizes that a survey is a consciousness-raising experience for a community and that not to follow through after raising expectations can be disastrous
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to developing credibility in the community.
Granby is located 80 miles from Denver in Grand County. The county is on a high plateau surrounded by mountains to the south, east and west. These mountains also divide the county into two distinct areas, east and west Grand County. The town of Granby serves as a hub for shopping and services in east Grand County. Fraser, Tabernash and Winter Park are south of Granby, Grand Lake is north west and Hot Sulphur Springs is west of Granby.
Although the year round population of Granby is reported in preliminary census reports to be 936, the area experiences wide fluctuation in seasonal visitors. In the winter, the ski. areas of Winter Park, Berthoud and Idlewild are very busy; in 1980-81, Winter Park was the second busiest ski area in the state, with 886,358 skier days. In the summer, a variety of dude ranches operate in the Winter Park area and Lake Granby/ Shadow Mountain Resevoir attract fishermen. Grand Lake is one mile from the Western Portal of Rocky Mountain National Park, a park that had 2,654,197 visitors last year.
While east Grand County is slated for future growth, it is considered a rural area (non farm) for census purposes. There are a number of health delivery problems which are peculiar to rural areas like Granby. Geographic isolation can mean travel of great distances for routine or primary care.(11) Although thirty percent of all Americans live in rural areas,
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only 17% of the country's primary care physicians serve these areas.(12)
GRAND COUNTY POPULATION
1970 1980 % Change
GRAND COUNTY 4,107 7,475 82.0
Fraser 221 470 112.7
Granby 554 963 73.8
Grand Lake 189 382 102.1
Hot Sulpher Springs 220 405 84.1
Winter Park 480
Subtotal 2,700
Kremling 764 1,296 69.6
4,196
Rural populations are generally characterized by low income, hazardous occupations, a higher proportion of senior citizens and lower educational levels. The lower income of rural populations confounds the health delivery problem in two ways:
1) people of lower income require more services but 2) may be unable to pay for them.(13) Ferretti discusses the impact this economic factor has on the primary care physician by citing a survey which found that the majority of low earners, those earning less than $30,000 per annum were primary care physicians or solo practitioners. The median income for private physicians in the United States was $58,440 after expenses.(14)
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4
N
i.
25 milei
J
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Another problem of rural physicians is the reluctance to set up practices which are geographically and technologically isolated from the specialists and sophisticated equipment with which they trained.(15) The families of physicians may be unwilling to locate in areas which are socially or culturally remote. The mayor of Grand Lake recounted an anecdote about the year that all the families in the area chipped in $150 a piece to salary a physician. The physician was able to stay only one year before leaving; "he had to leave so his kids could go to school."
This was the initial problem which moved the existing local physician to contact Saint Anthony for help. High physician turnover and problems with billing and accounting prompted the doctor to explore a management arrangement with the Denver Hospital. Affiliation with a major tertiary hospital would prove attractive in recruiting doctors. In addition, the physicians would not be spending as much time on billing and personnel matters.
The community of Granby listed resolution of doctor problems as the single most important action that would make the community a healthier place to live. Each time a physician leaves, members of the community who have sought care become more frustrated. Some of the people in the area "give up" after telling a new doctor each year a complete medical history. Those who give up, simply leave the community to get primary
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care. It is important that a community and client believe that they can build trust and confidence in a physician. The "caring" aspects of primary care are as important as medical treatment.(16)
But the loyalty and commitment of a doctor to a rural area carry a big price tag. These physicians must be willing to practice and be available 24 hours a day. This can be an overwhelming responsibility to the solo practitioner.(17) The first priority of the National Health Planning Law was to improve access by health care services to medically underserved, especially rural or economically depressed areas. Without the political clout
of large urban populations, it is difficult for rural areas to remedy these deficits. A number of governmental programs have been developed and coordinated under the auspices of the Rural Health Initative to resolve the problems of rural areas. Ahern has described these programs in Health Care in Rural America as follows:
Community Health Centers operated with grants provided to health organizations in medically underserved areas.
Unfortunately, a disproportionately large number of users were from urban areas even though 55% of medically underserved area population lives in rural areas.
Migrant Health Centers dedicated to migrant workers.
National Health Service Corps salaried health personnel are placed in qualifying rural areas. Federal dollars also support administrative costs.
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Primary Care Research and Demonstration (formerly Health Underserved Rural Areas) funds demonstration projects or research in primary health or dental services.
Rural Health Clinic Service Act extends medicare coverage to physician's assistants. Eligible health clinics have declined participation due to inadequate reimbursement and overwhelming paperwork burden.(18)
Loan Repayment Program provides money to pay for medical education of professionals agreeing to practice in rural areas for specified time periods.
Community Facility Loans loans are provided for construction of essential community facilities at a competitive interest rate.
All of these programs are likely to face serious funding cutbacks in this administration's budgeting process.
It is doubtful that Grand County could meet the stringent requirements established for participation in these federal programs. There are eleven physicians licensed to practice in Grand County for a population of 7,475. In spite of this high physician to population ratio, survey results from Granby do confirm that the community feels many of the pressures these federal programs were created to resolve. Saint Anthony Hospital Systems regards this as an opportunity for private
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industry to plan for the future health needs of the area
and wherever appropriate, work with the community to meet those
needs.
The community was most responsive to the development of the clinic. A number of key informants interviewed by the staff were anxious that the air ambulance service, Saint Anthonys'
Flight for Life, be continued. Forest service officials were especially concerned about air ambulance services for seriously injured skiers or mountain climbers. Many people regard access to health care as the need for services in life or death situations. There is a tendency not to plan for day to day, routine health services, probably because routine and preventive care represents an out of pocket expense. The clinic was designed to provide primary care services, emergency services, and air ambulance services when more sophisticated services not available in the area were needed.
Some opposition was heard from Kremmling physicians and hospital administration. An increasing number of Americans who are not affiliated with a physician use a hospital emergency room in place of the doctor's office.(19) This utilization may be more costly because hospitals have a much higher overhead than physicians^ offices. The closest hospital to Granby,.Kremmling Memorial Hospital, voiced concern about the clinic affiliation with Saint Anthonys. This 20 bed hospital has been operating at less than 50% capacity for several years. The hospital
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is not accreditated and perhaps, like other small rural hospitals, was fearful that the Granby clinic affiliation with a Denver hospital might spell further reductions in the local hospital utilization and potential demise.
Saint Anthonys had tripled the number of referrals to the Kremmling Hospital with a similar clinic located in Frisco, Colorado. But current trends are toward outpatient and ambulatory services and all hospitals are facing reduced inpatient days. For small hospitals with high fixed costs, any reduction in admissions is very threatening.
Affiliation with a hospital is very important for rural doctors. Hospitals provide a source for continuing medical education, the means to keeping a doctor's skills sharply honed. One aspect of this licensure of the Granby Clinic is the state requirement that any licensed clinic must provide a peer review and audit mechanism to monitor the quality of care provided by professionals. A number of community residents voiced the fear that should a patient complain about a doctor1s care to the doctor, there might be some punitive action taken. They feared the next time they needed a doctor, he would be "unavailable."
Since technically, peer review will be conducted by other professionals, a second board is being created to oversee the activities of the clinic. This lay board will be comprised of interested local community members and elected officials. It
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will include one or more representatives of Kremmling. This arrangement has worked well in Summit County where Saint Anthonys has licensed a similar clinic. One representative from the Summit Medical Center board sits on the Saint Anthony Hospital Board as well.
These types of clinics, designed to meet stated community needs and demands can be developed by private industry to resolve the health delivery problems of rural areas. Benefits to the community are many and with effective organization and communication, problems can be handled swiftly. A hospital can bring tremendous resources to a rural community needing services. The clinics serve as a first rung to primary health care services and allow for the orderly and rational regionalization of care.
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The Assessment
Information for the community based needs assessment was collected by mailed questionnaire and telephone followup. The data provided a means to assess individual and collective health problems including social and economic factors which influence the need and demand for services. This information would then be translated into a program of community health education or system changes which would be tailor made for the self reported needs of the community.
Since community needs assessment has not been typically done by hospitals, this survey was undertaken as a learning experience for Saint Anthony. The hospital planner consulted with experts working at the University of Colorado Health Sciences Center, the Colorado Department of Health, the local census bureau and the Department of Local Affairs. The survey helped to identify a constituency for the hospital as well as providing a forum for discussing dissatisfaction with existing or proposed services. Because this is the first needs assessment undertaken by a private hospital, Saint Anthony is developing a community perspective on institutional programming.
Scientific accuracy and precision were important in conducting the survey, but timeliness and usefulness were paramount. The hospital administration wanted a profile of community characteristics and desires. The information from the study will also be made available to the community board which will oversee
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clinic activities, to elected officials and the community at large.
The ultimate purposes of the study are to make the most of finite resources while considering the special social and economic features of the community. Certainly, an important benefit is the inclusion of the community in determining these priorities.
The survey was designed after reviewing a number of other research instruments used in Colorado, notably the Prescription for Primary Health Care, a Community Guidebook (1976), health questionnaires distributed in Sterling and Greeley and an unpublished document to assess user satisfaction and need.
The information gathered was intended to reflect the relationships between demography, health status, resources and their use and cost.
A rudimentary attempt has been made to compare the demography of Granby to that of Grand County and Colorado. The ultimate goal of this type of population based survey would be the establishment of rates for comparison as White states, "within and across geopolitical jurisdictions and over time."(20)
Such a comparison would require careful statistical analysis for bias and error and constant attention to the problems created when characteristics of a large population are compared to a small population.
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COMPARISON OF AGE DISTRIBUTION
Age 0 4 519 2044 45 64 65 +
______ granby
______ grand county
Colorado


Before designing the questionnaire (and developing the clinic in Granby), the planner spent one week in the Granby area meeting with community members to become familiar with local health perceptions. At civic club meetings information was provided about the proposed clinic. The timing was such that both husbands and wives attended these public informational meetings. The town of Winter Park invited St. Anthony staff to provide information to the town council and to work with the town planner. "Key informants" were interviewed in Grand Lake, Hot Sulphur Springs and Winter Park. Three meetings were held with the board and administrator in Kremmling. A series of press releases were carried by the Sky High News, the local newspaper. Before mailing the questionnaire out to the total community, the survey was piloted to ten individuals. Upon return of the pilot survey, changes were made in ambiguous questions dealing with difficulty in getting care as well as those questions
dealing with how respondants pay for health care services.
Unfortunately, not all ambiguity was eliminated: twenty seven of 42 incomplete responses to household member age question made a single check mark beside the age category. Since 27 respondants were married, it was assumed that instructions were not clear. Subsequent surveys will provide an example of how potentially confusing questions should be answered.
The questionnaire was standardized with predominately fixed
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alternative questions. One error was the omission of a blank space for "other" in the ranking of difficulty in getting care.
The questionnaire concluded with an open ended question about "what would be necessary to make Granby a healthier place to live". Questions were provided for cross check and included yes-no responses as well as checklists. Ranking scales were used to measure perceptions of difficulty in getting care and chronic health problems. Other scales were designed to measure perception of health, travel distance to clinics and income.
The Granby telephone directory was used to build the list of potential respondents. We assumed that the majority of households would have a phone. All obvious business addresses were deleted and labels for every listing were prepared. During the week of September 22, 1980, questionnaires were mailed to 639 households.
A coding device was developed to identify non-respondants for follow up mailings.
Returned envelopes were primarily from people who had moved. Additionally the Post Office in Granby culled those addresses which were not in Granby. A number of small communities are proximal to Granby (Fraser, Tabernash) and apparently selected households chose to list telephone numbers under the Granby listing.
Two hundred and twelve questionnaires were unforwardable leaving a universe of 477 households. After two successive mailings and a telephone followup, 332 responses were received for a response
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rate of 70%. This compares favorably to response rates recorded between 26 and 50% in the literature.(21) Additionally, census information shows households in Granby, with a total population of 963. Responses described a total of 896 family members or 93% identified in the census.
Questions were asked at a number of different levels of specificity to get both general as well as specific issue related responses.
An example of cross checking various questions involves asking the respondant about their perception of individual health status and cross checking with eating and sleeping habits which are considered health status indicators.(22)
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RESPONSES AND COST OF
MAILED QUESTIONNAIRE
RESPONSES 332
BASE 477
RESPONSE RATE 70%
QUESTIONNAIRES RESPONSES %
First Mailing 689
Unforwardable 212
477 147 31%
Second Mailing 330 96 51%
Third Mailing 234 69 65%
Phone 20 70%
TOTAL 1,041 332
TOTAL VARIABLE COST
Total Mail Out Postage 1,041 x 15t = $156.15
Total Business Reply 312 x 271 = 84.24
Envelopes 1,041 21.75 = 21.75
TOTAL $262.14
Cost per Returned Questionnaire $ .79
Other costs, such as staff time are "fixed," that is they should not be included because they would be costs regardless of the project. This corresponds favorably with comparable costs for mailed surveys of $1.64* per returned questionnaire.
* Andrew Lee Hinkle and Glen D. King: A Comparison of Three Survey Methods to Obtain Data for Community Mental Health Program Planning. American Journal of Community Psychology. Vol. 6, No. 4, 1978, p. 393.
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The Results
The universe was 477 households. There were 332 responses for a response rate of 70%. Census information indicates there are only 433 households which would yield a response rate of 77%. Respondents identified 896 family members; census information indicates the 1980 population of Granby to be 963.
The first two questions provided marital status and sex. Eighty percent of the study population is married. Fifty five percent are female.
The distribution of household member ages are as follows:
Age Distribution in Granby, Colorado Responses = 290
Ages Respondents %
0-5 105 12
6-18 198 22
19-44 371 41
45-65 168 19
66 + 54 6
Total 896
Total Incomplete Questionnaires 42
Granby has a higher percentage (10%) of children aged 0-4* than
Grand County (4%) or Colorado (7%). This younger population has
a higher risk for acute diseases such as bronchitis
* All ages were modified to conform to census categories.
Equal distribution among the ages was assumed.
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and ear infections. Granby (7%) has a lower percentage of the elerly than Grand County (10%) or Colorado (9%). The elderly have a higher incidence of chronic disease.
AGE COMPARISON GRANBY*, GRAND COUNTY, COLORADO
GRANBY GRAND COLORADO
AGE # % # % # %
0-4 87 10 337 4 216,056 7
5-19 230 25 1,286 17 669,530 23
20-44 357 40 3,126 40 1,150,653 41
45-64 160 18 2,218 29 503,234 18
65+ 62 7 813 10 251,853 9
896 7,700 2,791,325
COMPARISON OF SEXES 3Y PERCENT
GRANBY
Male Female
46% 54%
GRAND
Male Female 55% 44%
COLORADO Male Female 49% 51%
*Granby age figures were adjusted for purposes of comparison of study population to preliminary 1981 census data.
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COMPARISON OF SEXES
GRANBY
GRAND
COUNTY
COLORADO
%
male
C female


The self perceived health status of the area is very good (82%) with only 4% of the responses registered as poor or very poor. This was substatntiated by the cross checks of good appetite, 97%, and sleep well, 90%. Sixty one percent of the population (192) had sought care in the last 3 months. Of those who sought care, 55% were males.
Accessibility was measured by a series of questions. Distance to the nearest facility was within 10 miles for 83% of the population however, 261 (83%) respondents found this travel difficult. Cross checks with subsequent questions about weather or travel difficulties did not support this high response to difficulty. It remains unexplained.
Difficulty getting care is another measure of accessibility. Respondents placed the following problems in rank order with number 1 ranked as most difficult:
1. Too long a wait
2. Financial
3. Trouble getting an appointment
4. Weather conditions
5. No doctor
A study commissioned by the then HEW (HHS) ranked out of pocket expense as causing the most dissatisfaction with time waiting to see the doctor as second most dissatisfying aspect of getting care.(23)
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Only 51% of the respondents indicated they had difficulty getting care. This data must be used very caustiously.
In responses to satisfaction with care 235 persons responded with satisfaction.
The distribution for paying for care was as follows:
Payer Responses
Medicare 45
Medicaid 16
Private 239
None 21
figures were distributed as follows
Below $4,000 12
$4,000 to 7,500 17
$7,501 to 12,500 47
$12,501 to 20,000 90
Above $20,000 104
The income category below $4,000 of 16 respondents agrees with medicaid responses of 16.
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Income By Household Size N = 270
# members in household
Income 1 2 3 4 5 6 00 r- Total
Below 4,000 7 3 1 1 12
4,001 to 7,500 9 5 1 2 17
7,501 to 10,000 4 6 3 1 2 16
10,001 to 12,500 3 13 3 7 4 1 31
12,501 to 20,000 7 26 13 31 10 3 90
Over 20,000 4 31 20 33 7 6 3 104
Total 34 84 41 74 23 11 3 270
Undefined 4 6 3 10 1
Average family size = 3
Median income $12 ,501 to 20 ,000
(The 1978 per capita personal income for Grand County residents was $7,432.)
Of those respondents who indicated they had financial difficulty getting care, income is broken out as follows:
Income Financial Hardship
Below $4,000 6
$4,001 to 7,500 6
$7,501 to 10,000 8
$10,001 to 12,000 8
$12,001 to 20,000 23
$20,001 - over 12
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The Chronic conditions of the study population were distributed as follows:
HEALTH PROBLEMS N = 826
RANK PROBLEM RESPONSES %
1 Trouble seeing (corrected with glasses) 168 20.3
2 Allergies (hayfever) 109 13
3 Back/Neck Trouble 92 11
4 Arthritis 86 10
5 High Blood Pressure 49 5.9
6 Hearing Trouble 43 4.7
7 Gynecology 40 5.2
8 Heart Condition 42 4^ 00
9 Other (Undefined) 39 5
10 Ulcer 35 4.2
11 Asthma 31 3.8
12 Cancer 23 2.7
13 Hernia 22 2.6
14 Lung Condition 18 2
15 OB 15 1.8
16 Diabetes 14 1.6
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Chronic Diseases by Order of Prevalence
Self Reported Chronic Diseases by Order of Prevalence_________
Study Population
1 Rank Disease Rank Disease
1 Obesity 1 Trouble Seeing
2 Mental Disorder 2 Allergies
3 Heart Disease 3 Back/Neck Trouble
4 Arthritis 4 Arthritis
5 Other dis. of female genital organs 5 High Blood Pressure
6 Hypertension (w/o heart involvement) 6 Inpaired Hearir
7 Neoplasm 7 Gynecology
8 Hemorrhoids 8 Heart Conditiox
9 Other Symptoms, senility & ill-defined causes 9 Other (Undefined)
10 Varicose Veins (lower extremities) 10 Ulcer
11 Hay Fever, Asthma, Other Allergies 11 Asthma
12 Hernia of Abdominal cavity 12 Cancer
13 Syphillis 13 Hernia
14 Orthopedic impairments 14 Lung Condition
15 Low Back Strain 15 OB
16 Diabetes Mellitus 16 Diabetes
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New services desired by the community were listed as:
1. Physical therapy
2. OB-Gyn
3. Other
Under the heading of what could be done to make this a healthier place to live responses were:
Rank N %
1. Resolve doctor problems 91 38
2. Reduce Health Costs 61 25
3. 24 Hour Emergency Care 40 16
4. Water Improvement 25 10
5. Nutrition/Health & Education 20 8
237
The Projections
Interestingly enough, a check with the Colorado Department of Health epidemiologist indicates that there is indeed a problem with the water in Granby. There are two investigations of water borne infections currently under way.
Age tables provide a significant amount of information. Literature was reviewed to determine likelihood of utilization or need. These indicators of utilization are used with the following assumptions:
1. Granby study population is similar to national studies
-35-


used to compile data.
2. The range of projections may be overstating need because they are based on professional opinion about ideal use of services. For example, The Roddy indicator for well child care states that the population 0-11 months would require 7 visits per annum. In all likelihood, the Academy of Pediatricians has adopted the figure of 7 visits to conform to this model:
2 weeks 1
2 months 1
4 months 1
6 months 1
9 months 1
1 1
visit
visit for shots
visit for shots
visit for shots
visit
visit for bronchitis
visit ear aches, etc.
But new babies in rural areas may not visit a physician that often because of geographic or economic problems in getting care.
3. Although utilization is projected, it may not be appropriate. For example, not all colds or upper respiratory infections require a physician. It is very difficult to quantify these differing values among patients and physicians.
4. The questionnaire was mailed to households with a phone. Seventy percent of the population responded. The thirty percent which did not respond coupled with the population which does not have a phone could cause an error in estimates.
-36-


5. Using these indicators assumes that all of one population would go to one clinic. In reality, the population may go to other physicians, other clinics or leave the community. To project 7 visits per child 0-11 months at one clinic does not recognize those parents who take their children elsewhere.
6. Rapid population changes and seasonal fluctuations will affect the projections. For planning purposes the data set must be amenable to change or modification. For example, the majority of the Granby population is between the ages of 17-44. As this population ages, planning must change to meet the older population needs. Seasonal fluctuations of tourism may require additional services for acute disease or injury.
The following tables provide a range of indicators of need for health care services.
-37-


Annual Incidence/100*
AGE STUDY POPULATION ACUTE CONDITIONS CHRONIC CONDITIONS
0-5 105 388.1 29
6-16 168 265.4 29
17-44 401 213.4 120
45-64 160 131.3 120
65+ 62 101.7 269
# Visits Required/Conditions*
STUDY
AGE POPULATION ACUTE CONDITIONS CHRONIC CONDITIONS
0-5 105 2 1.5
6-16 168 2 1.5
17-44 401 3 3
45-64 160 3 3
65+ 62 3 7
* Roddy, Pamela C., Ph.D
"Need-Based Requirements for Primary Care Physicians, JAMA, Jan. 25, 1980. Vol. 243, No. 4. p. 356.
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AGE GRANBY STUDY POPULATION WELL CHILD CARE # VISITS REQUIRED/CHILD*
0-11 mos. 17 7
12 mos-4 yrs 72 4
5-9 78 2
10-14 76 2
15-19 78 1
GRANBY POPULATION LESS THAN 17 YEARS CENSUS PROJECTIONS POPULATION 17 YEARS*
GRANBY % '75 '80 '90
273 30.5 31.1% 28.4% 27.6%
* Roddy, Pamela C., PhD., "Need-Based Requirements for Care Physician," JAMA, Jan. 25, 1980. Vol. 243, No. 4,
Primary p. 355-356.
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390
330
270
210
150
90
30
0
ANNUAL INCIDENCE/100 CHRONIC & ACUTE CONDITIONS
acute
chronic
Age
0-5
6 16
17 44
45 64
65 +
Roddy, Pamela C., PhD.: Need-Based Requirements for Primary Care Physicians, Journal of American Medical Association, Jan. 25, 1930-Vol. 243, No. 4, p. 356.


Annual Incidence/100
Acute Conditions Chronic Conditions
'80 '78 '12
Age Roddy GMENAC Schonfeld Roddy GMENAC Schonfeld
0-5 388.1 303.4 180 29 29 29
6-16 265.4 230.3 180 29 29 29
17-44 213.4 172.8 109 120 120 120
45-64 131.3 98.3 109 120 120 120
65+ 101.7 75.7 81 269 269 269
# Visits Required/Conditions
Acute Conditions Chronic Conditions
Age Roddy GMENAC Schonfeld Roddy GMENAC Schonfeld
0-5 2 2 2 1.5 1.5 1.5
6-16 2 2 2 1.5 1.5 1.5
17-44 3 3 3 3 3 3
45-64 3 3 3 3 3 3
65+ 3 3 3 7 7 7
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1980 Low Estimate
Study Population x HSA Factor = Est. t Visits
Ages
0-5 105 6.2 651
6-14 137 3.1 425
15-24 145 4.1 595
25-34 143 4.4 629
35-44 143 4.2 601
45-54 80 4.7 376
55-64 80 5.7 456
65+ 62 6.1 378
Total Visits 4 ,111
1980 High Estimate
Ages Study Population v Roddy Estimated # Visits
0-5 105 12.4 1,302
6-14 137 7.7 1,055
15-24 145 10.2 1,407
25-34 143 10 1,430
35-44 143 10 1,430
45-54 80 7.5 600
55-64 80 7.5 600
65+ 62 21.9 1,358
Total # Visits 9,182
# Visits per Person
per year
Roddy-1980
Ages HSA Data
0-5 6.2 12.4
5-14 3.1 7.7
15-24 4.1 10.2
25-34 4.4 10
35-44 4.2 10
45.54 4.7 7.5
55-64 5.7 7.5
65+ 6.1* 21.9
*averaged for comparative purposes
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AGE GRANBY STUDY POPULATION OFFICE VISITS/PERSON* TOTAL VISITS
C15 243 2 486
15-24 145 2.2 319
25-44 286 2.7 772
45-64 160 3.3 528
>65 62 4.1 254
Total Visits = 2,359
GRANBY STUDY OFFICE VISITS
POPULATION BY SEX*
Male 412 3.2
Female 484 2.2
* The National Ambulatory Medical Care Survey, 1977 Summary (Jan-Dec 'll), US DHEW, Vital and Health Statistics, Series 13, No. 44, p. 17.
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Incidence Rates of Selected Measures of Job-Related Health Conditions for Hired Workers, By Industry, 1976
Industry JobRelated Fatalities per 1,000' Projected for Grand County Illness Injury/100 Projected for Grand County
Mining Agriculture/ .49 .00049 11.0 .11
Forestry .28 .007 11.0 3
Construction Transportation/ .25 .08 15.3 48
Public Utilities .19 .02 9.8 9
Manufacturing .06 .007 13.2 16
Services .05 .07 5.3 76
Wholesale/Retail Finance, Insurance/ .04 . 03 7.5 63
Real Estate .01 .002 2 5
1
U.S. Department of Labor, Chartbook on Occupational Injuries and Illnesses in 1976. BLS Rpt., 535, 1978
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US Household Interviews Compared to Colorado Utilization
National Acutel % Utilization of Coloradc Conditions/100 __________Rural Practices
Infective & Parasitic Diseases Respiratory Conditions Upper Respiratory Conditions Influenza
Other Respiratory Conditions Digestive System Conditions Injuries
Fractures, Dislocations, Sprains, and Strains
Open Wounds and Lacerations
Contusions and Superficial Injuries
Other Current Injuries
23 17%
111.4 37%
56.2
48.9
6.2
10.5 7%
34.2 19%
11.1 9%
8.6
6.5
7.9
^ Outside SMSA, Non Farm, Acute Conditions Incidence and Associated Disability, United States, July 1977-June 1978. National Center for Health Statistics, Series 10, No. 132, US Department of Health, Education and Welfare, September 1979, p^ 23.
2
6,101 Patients, "Differences in Morbidity Patterns Abmong Rural, Urban, and Teaching Family Practices: A One-Year Study of Twelve Co-orado Family Practices," The Journal of Family Practice, Vol. 9, No. 6: p. 1078, 1979.
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Range of Physician Specialty Requirements (Physician/100,000 Population)
Study Population 2,700 (East Grand County)
Physicians/100,000 Proj. for Physicians/100,000 Proj. for
Low Estimate* St. Pop. High Estimate* St. Pop.
Specialty rimary Care
Gen. & Fam.
Practice 11.5 .3 55.0 1.5
Internal Med. 5.0 .14 96.0 2.6
Pediatrics 4.0 .1 37.0 1.
edical Specialties
Allergy 2.0 . 05 4.0 .1
Cardiology 1.0 .03 6.0 .16
Dermatology 2.0 .05 6.0 .16
urgical Specialties
General Surg. 8.0 .2 15.2 .4
Neurosurgery 0.9 .02 1.4 .04
Opthalmology 0.5 .01 5.8 .16
Orthopedic Surg. 1.0 .03 6.3 .17
Otolargyngology 1.0 .03 23.0 .6
Plastic Surgery 0.6 .02 2.2 .06
Thoracic Surg. 0.5 .01 1.1 .03
Urology 1.0 .03 5.0 .14
ther Specialties
Anesthesiology 2.0 .05 12.0 .3
Neurology 1.0 .03 5.0 .14
Pathology 1.0 .03 6.9
Psychiatry 2.0 .05 54.4 .19
Radiology 3.0 .08 13.0 .35
* Review of Health Manpower Population Projections, DHEW Publication No. (HRA) 77-22, October 1976.
-45-


Conclusion
St. Anthony Hospital Systems is preparing a report of these activities to be presented to the Grand County Commissioners at a public meeting. Aside from publishing the data which were collected, the hospital has begun working on a program with the physical therapy department which can be provided at the clinic in Granby. Since back and neck trouble ranked as the third most prevalent problem and arthritis, as the fourth, this program will be responsive to community perceived need. Physical therapy was listed as the first choice for new services and the hospital is eager to pilot a project in Granby.
Only 48 of some 254 respondents knew that an optometrist was available. Because "trouble seeing (corrected with glasses)" was listed as the most prevalent problem the hospital will publicize the days when an optometrist is available. Eye glasses are not usually covered by insurance and therefore, represent an out of pocket expense. For many Granby residents, a pair of glasses may last a life time.
New programs such as allergists rotating through the clinic once a month or hypertension screening clinics can be undertaken. Saint Anthony can proceed item by item, down the list of services, determining feasibility and holding costs down whenever possible, while at the same time making physicians and staff available on a needed basis.
-46-


Perhaps the most significant aspect of the project is the ability to link data collection with action. The hospital is committed to building credibility in the community. This type of needs assessment allows the community to participate in shaping health care services. For a hospital to "relinquish" a portion of its power and decision making authority to the community is a crucial first step to population based planning and a more equitable distribution of health care services.
-47-


^Anthony L^ospitad Systems
July 30, 1980
Thank you very much for participating in my study! You are one of 10 "reviewers" reading and cementing on the enclosed questionnaire. I have enclosed a stamped, self-addressed envelope for you to mail your cements to me by Monday, August 25, 1980.
You should complete the questionnaire just as if you were taking an exam except that you should make cements about words, phrases, or anything that seems confusing.
This "pilot study" will be used to shape up the final questionnaire to be administered in Granby, Colorado. The needs assessnent will be conducted the first week in Septariber. It will be a study to determine what health care services are needed in the area. We hope to adapt this first needs assessment to other ccmunities as well.
Thanks again for your help in making health planning work for your ccmunity!
Sincerely,
Barbara K. Stuart Health Planner
APPENDIX
Central: 4231 West 16th Avenue, Denver, Colorado 80204, 629-3511
North: 2551 West S4th Avenue. Westminster. Colorado 80030. 426-2151


PILOT QUESTIONNAIRE RESPONDENTS
1. Steve Bromberg P.O. Box 664
Granby, Colorado 80446
2. Allen Carbin Mayor, Grand Lake Box 605
Grand Lake, Colorado 80447
3. Marvin Fischer
Chief Building Inspector Court House
Hot Sulphur Springs, Colorado 80451
4. Judy Gambino
Snith & Company (Business Manager) Box 240
Hideaway Park, Colorado 80450
5. Linda Gehrens P.O. Box 83
Hot Sulphur Springs, Colorado 80451
6. Chris Ivie P.O. Box 43
Hot Sulphur Springs, Colorado 80451
7. Judy Layton
County Court House (Data Processing) Hot Sulphur Springs, Colorado 80451
8. J. R. Steward Box 588
Grand Lake, Colorado 80447
9. Bob Woodberry Box 36
c/o Winter Park Ski Area Winter Park, Colorado 80482


QUESTIONNAIRE
PLEASE FILL IN THE QUESTIONS BELOW:
Are you currently: _______ Married
_____ Single
Divorced
Sex: Female
__ Male
How old are the people in this household, and how many are there in each age group? Please write the number in the space provided and include yourself as a household member.
______ 0-5
______ 6-18
______ 19-44
'_____ 45-65
______ 66 +
SOME QUESTIONS ABOUT YOUR HEALTH
Would you describe yourself as a fairly healthy person or not very healthy? (Check one.)
_____ Very Good Health
_____ Good Health
_____ Adequate Health
_____ Poor Health
. Very Poor Health
Do you have a good appetite? _______ Yes __________ No
Do you sleep well at night most of the time? ________ Yes __________ No
GETTING CARE
Have you been to see someone in the last three months because you were not well? _______ Yes _________ No
Is health care close enough to you, or do you have to travel a great distance for care?
0-5 Miles 21-40 Miles
6-10 Miles 41-100 Miles
11-20 Miles
Do you find this traveling easy to manage or is it in anyway a problem? __________________________ Easy
______ It is a Problem
During the past year have you found it difficult to get medical care when you needed it?
Easy __________ Hard __________ Did Not Need Care
l


Ques cionnaire
Page 2
If hard to get medical care when you needed it, mark all that apply:
______ Financial
______ Lack of Transportation
______ Language Problem
______ Couldn't Find a Doctor
______ Went but had to Wait Too Long
______ Trouble Getting an Appointment
Other
Overall-, would you say that you are reasonably pleased with the care chat you received? ______ Yes ___________ No
PAYING FOR CARE
Do you usually pay for health care yourself? ________ Yes
No
Do you have health insurance that pays for some or all of your care?
Yes _____ No
If yes, does insurance pay? _______ Some _______ All
Do you have health insurance under? ________ Medicare
Is your income?
Below $ 4,000 a year From $ 4,000 to $ 7,500 From $ 7,501 to $10,000 From $10,001 to $12,500 From $12,501 to $20,000 Above $20,000
Medicaid
Do you have any of the following health problems?
Yes Under Doctor's Care
Arthritis _____ _______________
As thma _____ _______________
Lung Condition _____ _______________
Diabetes _____ _______________
Heart Condition _____ _______________
High Blood Pressure _____
Cancer _____ _______________
Back Trouble _____ _______________
Hearing Trouble (corrected with hearing aid?) _______ _______________
Trouble Seeing (corrected with glasses?) _____ _______________
Hernia _____ _______________
Ulcer _____ _______________
Allergies (hayfever) _____ _______________
Do you have any other health problem chat is not mentioned in the list above? Please write in. _________


Questionnaire
Page 3
When you consider this possible list of services, are there any that you feel would be useful additions to services already present in your community?
Could Be Would Be Not
Very Useful Nice To Have Needed
Family Planning _____ ______________ __________
Dental Services _____ ______________ __________
Physician _____ ______________ __________
Ophthalmic (eye care) _____ ______________ __________
Orthopedic (bone care) _____ ______________ __________
Nurse Practitioner (physician helper) _______ ______________ __________
Pharmacy _____ ______________ __________
Well Child Clinic _____ ______________ __________
Physical Therapy _____ ______________ ____________
What do you think are the most important things to do in this community to keep it healthy or to make it a healthier place in which to live?


QUESTION
1
2
VALUE FOR FUTURE
COMMENTS . QUESTIONAIRE
MARITAL STATUS -
80% of the study population is married. Add "Widowed" response
14% are single and 6% arc divorced.
SEX
55% Female 45% Male
HOUSEHOLD MEMBER AGES
AGE NUMBER PERCENT Change to 5 year increments to correspond
0-5 105 12% with census.
6-18 198 22%
19-44 371 41% Add line for total household
45-65 168 19% members including respondents
66+ 54 6%
PERCEIVED HEALTH STATUS *
82% good to very good 15% adequate 3% poor 1% very poor
5 HOUSEHOLD MEMBERS WHOSE
HEALTH IS PROBLEM
Did not yield any usable data
Omit


QUESTION COMMENTS
VALUE FOR FUTURE
QUESTIONNAIRES
6
7
8
9
10
11
GOOD APPETITE
Yes 312 97%
No 9 3%
SLEEP WELL
Yes 292 90%
No 32 10%
RESPONDENT SOUGHT CARE?
Yes 192 61%
No 122 39%
OTHER MEMBERS SOUGHT CARE?
No usable data WHO SAW A DOCTOR?
No usable data other than ratio male to female visits. Male visits = 30%.
DISTANCE TO FACILITY
!
0-5 miles 212 83% population within
6-10 miles 46 10 miles of service.
11-20 miles 25 21-40 miles 0 41-100 miles 29
6 and 7 are health status indicators; Positive statements support #4.
Must be cross-tabbed with 2 due to differences in male, female health status.
Omit
Confusing question. Omit?
Define"medical facility 29 respondents might have assumed hospital.


QUESTION
COMMENTS
12
TRAVEL DIFFICULTY
No problem 51 Somewhat of a problem 0 A difficult problem 261
13
14
15
16
DIFFICULTY GETTING CARE
DIFFICULTY GETTING CARE RANKS AS MOST DIFFICULT
1. Too long a wait
2. Financial
3. Trouble getting
appointment
4. Weather condition
5. No Doctor
SATISFACTION WITH CARE Yes Unanimous
WHO PAYS FOR'CARE?
17
18
INSURANCE AVAILABITY
INSURANCE PAY SOME OR ALL
VALUE FOR FUTURE
QUESTIONNAIRES
Although 83% of the population is within 10 miles of CARE, they perceived some difficulty in traveling.Cross tabs with weather or travel in 14 did not support this question.
Redundant Omit
Only 51% response rate. Careful inclusion
No valuable additional in- Omit
formation over #19.
No valuable additional in- Omit
formation over #19
Should be changed to get percentage pay or deductive figure.


QUESTION
19
20
COMMENTS
MEDICARE, MEDICAIBV PRIVATE INSURANCE
Medicare 45 Medicaid 16 Private 239 None 21
INCOME
Below 4000 16
4000 to 7500 21
7501 to 10,000 21
19,000 to 12,500 24
12,501 to 20,000 208
Above 20,000 0
VALUE FOR FUTURE
QUESTIONNAIRES
Change to private:
Pays for all inpatient Pays 80% all inpatient Pays all outpatient
Crosstabls with family size, financial difficulty getting care.
# 19 and #20 (Medicaid agrees) below 4,000 = 16
To Poverty Level


QUESTION COMMENTS
21 CHRONIC CONDITIONS
RANK Top 10 Conditions:
1 Trouble seeing (corrected with glasses)
2 Allergies (Hayfever)
3 Back/Neck Trouble
4 Arthritis
5 High Blood Pressure
6 Hearing Trouble
7 0 Gynecology
8 Heart Condition
9 Other (undefined)
10 Ulcer
VALUE FOR FUTURE
QUESTIONNAIRE
RESPONSES %
168 20.3
109 13
92 11
86 10
49 5.9
43 4.7
40 5.2
42 00 t
39 5
35 4.2
GROUPINGS TO PARALLEL VITAL STATISTICS:
Respiratory (Includes bronchitis pnemonia, cold,flu) Circulatory includes vascular, heart condition, digestiv metabolic(pancreas, liver, spleen, gall bladder)
Headaches, urinary system.


22 . Other Health Problems
23. New Services
1. Physical Therapy 2. OB ^ Gynecology 3. Other Chiropractors
24. What Could be Done To Make This A Healthier Place To- Be?
Rank N %
1 Resolve doctor problems 91 38
Medical Turnover 21
Shortage 20
Negative Existing 26
More Specialists 24
2. Reduce Health Costs 61 25
3. 24 Hour Emergency Care 40 16
4 . Water Improvement 25 10
5. Nutrition/Health & Education 20 8
237
Other Questions For Furture Surveys
Should request data on education and occupation as there are relationships between these factors and chronic conditions.*
Marcus, Alfred C., et al: Monitoring Health Status, Access to Health Care and Compliance Behavior in a Large Urban Community Medical Care, March 1980, Vol XVIII No. 3, p. 262.


Percent Distribution By Ages Granby, Colorado and U.S.
Ages Granby % Colorado % U.S.
0 1 .u 10 7 10
5-19 25 23 26
20-44 40 41 S5
45-64 18 18 20
65+ 7 9 10


FOOTNOTES
1. World Health Organization, "CONSTITUTION," In the First Ten Years of the World Health Organization (Geneva: W.H.O.,
1958).
2. President's Commission on the Health Needs, Building America's Health: A Report to the President. Vol. 2: America's Health Status, Needs and Resources (Washington, D.C.: U.S.
Government Printing Office, 1952-1953) p.13.
3. Logan, R.F.L., M.D.,"Assessment of Sickness and Health in the Community: Needs and Methods", Prepared for a European Technical Conference, sponsored by the Regional Office for Europe, World Health Organization, March 1963, p. 173.
4. Donabedian, Avedis, M.D., MPH: Aspects of Medical Care Administration. Harvard University Press, Cambridge, Massachusettes, 1976, p. 70.
5. Marcus, Alfred C., et al. "Monitoring Health Status,
Access to Health Care, and Compliance Behavior in a Large Urban Community," Medical Care, p. 258.
6. Wennberg, John E., M.D., Using Localized, Population-based Data in Evaluating Planning Problems. Papers on the National Health Guidelines: The Priorities of Section 1502. USDHEW,
Public Health Service, Health Resources Administration. January 1977 DHEW Public No. (HRA), p. 82.
7. ibid., p. 88
8. Mechanic, David. "Prospects and Problems in Health Services Research," Milbank Memorial Fund Quarterly/Health and Society, p. 131.
9. Schonfeld, Hyman K., et al. "Number of Physicians Required for Primary Medical Care," The New England Journal of Medicine. p.574.
10. Donabedian, Avedis, M.D., op cit, p.69.
11. Ahearn, Mary C., Health Care in Rural America, p.2.
12. "Rural Health Care," Information Bulletin, p. 3.
13. Ahearn, Mary C., op cit, p.2.
14. Ferretti, William P. "The Realities of Rural Primary Care, The Journal of Ambulatory Care Management, p.31.
II


17. Kasteler, Josephine M. and Charles C. Hughes. "The Rural Health Delivery Problem," Family and Community Health.
p. 61.
18. "Rural Health Care," Information Bulletin, p.10.
19. Ferretti, William P., op cit, p.33.
20. White, Kerr L. "Information for Health Care: An Epidemiological Perspective," Inquiry, p. 303.
21. Satcher, David, et al. "Results of a Needs Assessment Strategy in Developing a Family Practice Program in an Inner-City Community," The Journal of Family Practice, p.874.
22. Belloc, Nedra B. and Lester Breslow, "Relationship of physical health status and health practices." Preventive Medicine, Vol 1, August 1972,p. 419.


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